Basic Information
| Provider Information | |||||||||
| NPI: | 1013936764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STARK | ||||||||
| OtherFirstName: | CHRISTOPER | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 560825 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802560825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957580 | ||||||||
| FaxNumber: | 7195450176 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195952218 | ||||||||
| FaxNumber: | 7195957994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 50157 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 208M00000X | DR.0058428 | CO | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 39876 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64125065 | 05 | KY | MEDICAID | 9000147685 | 05 | CO | MEDICAID |